Post-Prandial Trouble! KPA 2017 Nutrition pre-congress case Presentation Dr. Esther Kimani. Facilitator- Dr. A. Laving. 25/04/2017

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1 Post-Prandial Trouble! KPA 2017 Nutrition pre-congress case Presentation Dr. Esther Kimani. Facilitator- Dr. A. Laving. 25/04/2017

2 Biodata. Name- I.M.M. Age-6 years Gender- female Referred to the Paediatric gastrology clinic from the Paediatric surgical clinic at KNH. Presenting illness- Vomiting since infancy

3 History of presenting illness Vomiting since infancy. Having about 5-6 episodes per day. The vomiting was post-prandial,nonbilous,non bloody and non projectile. Not associated with abdominal pain, diarrhoea or abdominal distension. No clear history of dysphagia, child preferred mashed foods and liquids. No chocking episodes during and after feeds.

4 Past medical history. Had 4 prior admissions. The 1 st 3 admissions. All for Severe pneumonia at 7months,12 months and 36 months of age. 4 th admission at KNH and had a surgical procedure done, 7 months earlier. Child had been on domperidone and omeprazole for 7 months post operatively. No history of atopy or chronic illness.

5 Birth History Ante-Natal- unremarkable Delivery- Born term via SVD,birth wght- 3.4 kgs,cried immediately after birth and had an uneventful neonatal period. Immunization- Up to date as per KEPI Development- Milestones were appropriate for age. Currently in Preunit. Noted to have been missing school severally per term due to the illness.

6 Growth and development Current weight was 15 kgs. Nutrition- Child was mainly fed on semi-solids and liquids, as these are the foods she preferred. Family social history. Lived in Machakos. 3 rd Born. Siblings were alive and well. Mother 38 year old- Primary school teacher.# Father 42 year old- primary school teacher. No known family hx of chronic illnesses.

7 Physical Examination. General exam. Fair general condition. No palour,jaundice,cyanosis,oedema. Vitals HR-101, Temp-36.7, RR-28. Sp02-95% on RA Anthropometry. Weight-15.8kg, Height-107 cm BMI BMI/Age- -1 Z score Height/Age- -1Z score Weight/Age- -1 Zscore. Systemic exam P/a- Midline scar, soft non-tender and no organometallic. Other systems were normal.

8 Differential diagnosis. GERD. Oesophageal stricture. Achalasia Cardia

9 Investigations Parameter TBC WBC Hb Mcv Mch Platelets Value 17.9( Neutr %) Serum Urea 3.1 ( ) creatinine 61 (20-70) sodium 136 Potassium 3.8

10 BARIUM MEAL. BEFORE SURGERY AFTER SURGERY

11 Barium meal report Mega oesophagus with barium retension. Delayed Oesophago-gastric emptying and a Narrow Gastro-oesophageal Junction.

12 Remember the Surgical procedure Heller s cardiomyotomy with a Nissen Fundoplication was done 7 months prior to the Paediatric Gastrology clinic referral.

13 What next??? OGD scheduled. Had GEJ dilatation- 3 sessions. Still on f/up at the Paeds Gastro clinic. Still on semi-solids feed but with better tolerance. Vomiting has significantly reduced. Gained some weight. She is now 16.5 Kgs. Still on domperidone and omeprazole.

14 ACHALASIA CARDIA IN CHILDREN Achalasia is a primary oesophageal motor disorder of unknown aetiology. There is loss of LES relaxation and loss of oesophageal peristalsis. Functional obstruction of the distal oesophagus.

15 Pathophysiology. Inflammation surrounds ganglion cells, which are decreased in number. There is selective loss of postganglionic inhibitory neurons that normally lead to sphincter relaxation. Postganglionic cholinergic neurons thus unopposed. This imbalance produces high basal LES pressures and insufficient LES relaxation.

16 Management options 1.Medical therapy: Calcium channel blockers (Paucity of data in children) Botulinum toxin injection- symptom relief for 4/12 1,permanent relief in 10-40% adults Hurwitz M, Bahar RJ et.al Evaluation of the use of botulinum toxin in children with achalasia. J Pediatr Gastroenterol Nutr 2000; 30: [PMID: ] 2. Pasricha PJ, Ravich WJ et.al. Intrasphincteric botulinum toxin for the treatment of achalasia. N Engl J Med 1995; 332: [PMID:

17 2.Endoscopic pneumatic dilatation. Success rated of upto 90% in children with multiple dilatations. 3 The advantages of balloon dilatation: shorter hospital length of stay Quicker recovery time Decreased cost 3.Hamza AF, Awad HA, Hussein O. Cardiac achalasia in children. Dilatation or surgery? Eur J Pediatr Surg 1999; 9: [PMID:

18 3.Surgery. Most definitive and successful treatment of choice. Hellers myotomy with or without an antireflux procedure. Open vs laparoscopic. Complications: Recurrence of dysphagia(upto 26% of cases) 4 Oesophageal perforation 4. Corda L, Pacilli M, Clarke S et.al Laparoscopic oesophageal cardiomyotomy without fundoplication in children with achalasia: a 10-year experience: a retrospective review of the results of laparoscopic oesophageal cardiomyotomy without an anti-reflux procedure in children with achalasia

19 ASANTE SANA! Erokamano!

20 References. 1. 1Hurwitz M, Bahar RJ et.al Evaluation of the use of botulinum toxin in children with achalasia. J Pediatr Gastroenterol Nutr 2000; 30: [PMID: ] 2. Pasricha PJ, Ravich WJ et.al. Intrasphincteric botulinum toxin for the treatment of achalasia. N Engl J Med 1995; 332: [PMID: Hamza AF, Awad HA, Hussein O. Cardiac achalasia in children. Dilatation or surgery? Eur J Pediatr Surg 1999; 9: [PMID: Corda L, Pacilli M, Clarke S et.al Laparoscopic oesophageal cardiomyotomy without fundoplication in children with achalasia: a 10-year experience: a retrospective review of the results of laparoscopic oesophageal cardiomyotomy without an anti-reflux procedure in children with achalasia.